Medicine by Help Desk

Every month, the “Eye on PBMs” column in America’s Pharmacist, NCPA’s official magazine, highlights an example sent in by a reader of PBM abuse of independent community pharmacies and their patients. The following is from the November issue.
Medicine by Help Desk
“I practice in a rural independent community pharmacy that services long-term care facilities. Last fall I was processing a refill Rx for a patient for fluoxetine 20 mg. I got a rejected claim with the message for the patient to contact Caremark because refills were not allowed. I noticed we had filled this Rx for the patient a few times previously with no problem, so I called the help number listed. The Caremark representative told me that the patient was only allowed two fills at a local pharmacy and this was the third so he would have to fill at a CVS pharmacy or order by mail.

“If one searches for a CVS store by our ZIP code on our Web site, there are no matches. I told the rep that this patient was in a nursing home, and Oklahoma state law requires those Rxs to be unit-dosed. I asked if Caremark mail order would unit-dose for him. She said they would not, but he could still fill the Rx with us and submit the receipt to get up to 50 percent of the price reimbursed. This seems like an unreasonable thing to ask of someone living in a nursing home.

“Her final recommendation was to ask the prescriber to change the dose of the drug so that it would have two more local fills (since it would process as a different drug). As a health care provider, I feel this is the worst part of the story. Why would we ask to change a patient’s drug therapy based on a help desk representative’s recommendation? If we took this advice, would we just continue to change drugs and dosages every two—three months? This is not practical or beneficial pharmaceutical care. Please take these comments into consideration in the evidence against CVS/Caremark.”

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5 Responses to “Medicine by Help Desk”

I have a damn good example of a Caremark “Help Desk” idiot becoming a “Specialist” or “Analyst”-

A NEW customer brought in a prescription for Encort 30mg suppositories. Of course, AFTER I am through filling his rx, he whips out an insurance card- CAREMARK/CVS. So I go back, enter all of his insurance info, and submit the claim. I get a reject code “Non-formulary drug- blah blah blah- whatever-we-don’t-even-care” rejection code.

I inform my NEW customer that his insurance will not pay for that particular drug. He asks “Why?” I tell him “I have no clue- they cover what they want to, and that’s it. I am very sorry, but I have no “powers” to persuade your insurance company to cover your prescription. It costs $29.82- do you want it or not?” He said OK, paid us, then left.

A few minutes later, I get a call from some jack-leg that is a “Help Desk idiot turned “specialist” for Caremark. He says that my customer is on the line, and had called the insurance company to see why his drug was not covered. “That’s fine” I told the “specialist.” THEN the help-dest idiot turned specialist informed me that they DID cover that drug, but not anymore! Say WHAT??

Help-desk-idiot-turned-specialist started in with a line of BS that was unbelievable. He said that the drug had been discontinued, and that is why it was no longer covered, I told him, if it HAD been discontinued, the doctor, nor I, knew about it, and why did that even matter, when I HAD the drug to dispense? He kept telling me that I did not “understand” what he was telling me. He also informed me to “take the prescription back (felony), and see if the doctor will change it, since it was no longer available”!!!

I told him it WAS available, I was looking at a box right that minute, and he started saying that I was WRONG in telling the customer it was not covered, because it was covered if it had not been discontinued! I RAPIDLY begin losing any patience that I had left, and told him that HE did not understand what I was TRYING to tell HIM. He then said “It’s like, you know, if Wonder Bread was discontinued, then you could still buy Ideal Bread, or Colonial, or something like that, you know what I mean?” !!! I starting yelling “I HAD THE DAMN WONDER BREAD, so I dispensed it, and am looking at the other “LOAF” on my shelf, so what was the problem????!!!!!”

Oh hell yes, I hung up on the idiot! He basically, with my customer hearing every word, was telling me that I had “done wrong” when I told my customer that his drug was not covered, AND to take it back- actually telling me to COMMIT A FELONY!!!

NOW WHY DO WE HAVE TO EVEN DEAL WITH THIS IGNORANCE? If I was not the only pharmacist working in my family’s small, independent pharmacy, I would go back to college and become anything BUT a pharmacist!

Who knew that insurance companies/PBMs, drug companies, and the IDIOTS that work for them would end up being our boss, physician, and dictate what could be filled, and how much- I mean how LITTLE- that would be “paid” for it- 6 weeks later??? It is a nightmare that I NEVER anticipated 24 years ago!

I understand your frustration completely, and you have every right to be angry. I just wish you could express yourself in a more appropriate, professional manner. We don’t know who will be reading your response; if I were a legislator, your complaint would lose credibility, for it is so hostile. Using words like “damn” and “b.s.” when referring to the PBMs turns a legitimate complaint into a childish, emotional reaction.

I am on your side completely. Independent pharmacies will become a thing of the past if the current trend is allowed to continue. When we show unity as a group, and present our side in an articulate, intelligent fashion, we are more likely to be heard.

I apologize if the way I worded my “opinion” offended you, or anyone else. I can assure you that it was not intentional. However, I DO get hostile every time I think of what our “leaders” are doing to independent pharmacy, and even more so, to our senior citazens!

I was merely venting on a sore subject on what I thought was a PHARMACY blog. I did not think that any congressman would peruse through thousands of blogs, just to find out what pharmacists are saying, especially since we have been trying to tell them for years, and they have just begun to listen, MAYBE, if we are lucky.

I DO get “emotional” when I think of how Medicare-D was crammed down the throats of MY patients. I live in a rural area, and many of my patients are uneducated, poor, illiterate, and depend on ME to figure out EVERYTHING for them. It is an exhausting task that I am sick and tired of having to do, just because the insurance companies/PBMs have the upper hand in every aspect of our health care system.

Also, when I wrote my opinion, did you notice it was at 4:53 AM??? I did not get up early, I NEVER SLEPT BECAUSE I DID NOT HAVE TIME. I tend to get a little more agitated when I get less than 3 hours of sleep. I am still at work now, since 8:30 this morning, and will be here past midnight.

I can assure you, that I have been in constant communication with my State and US legislators since August 2005, and they value my insight. They see a person who does give a DAMN about PEOPLE, NOT WORDS.

I can also assure you, that when I write ANYTHING, I will SIGN MY NAME. I may appear to be “childish” to you, but I prefer to call it PASSION. I am not ashamed of what I believe in, therefore I am not afraid to reveal my name.